Physiologic Support Systems

Assessing these systems includes monitoring the infant’s respiratory patterns, heart rate, and skin color. The clinician should observe the intensity or severity of the signs present, not their absolute numeric values. Automatically mediated movements include tremors, startles, reflexive eye movements, and sounds such as whimpers and cries. The behavioral indications of decreased visceral control include hiccups, spitting up, gagging, and bowel movements. It is important to observe the baseline color of the infant’s skin during quiet sleep. Any changes from normal to dusky, pale gray or blue are abnormal.

Motor System

Assessing the motor system includes observations of the infant’s posture at rest and how it is modulated during movement in his or her environment or when stimulated. When observing the infant’s posture, the clinician should check for flaccidity, abnormal flexion and extension patterns, and tone that varies abnormally between hypertonicity and hypotonicity. Well-organized motor systems in infants demonstrate modulated tone and an ability to maintain flexion. Their movements are controlled without variability. Infants remain in a tucked position, maintaining flexor posture when grasping. Normal motor organization in infants includes the ability to brace, suck, and stabilize their posture in an appropriate position without swaddling. Motor disorganization in an infant is characterized by splaying of the arms or legs and arching movements with increased muscle tension during stimulation. Arms and legs may be hyperextended and hypertonic with rigid extensions or overly flexed with arms tight in to the chest. The clinician should note whether motor movements are diffuse, overly abrupt, or lack movement after effort. Further assessments of motor organization should be made while the infant is in transition from a sleep to an alert state, during routine medical procedures, when feeding, and while being held.

State System

Observations of eye movements, eye opening, facial expressions, gross body movements, and respiratory patterns should be made when the infant is in a sleep state, in transition from sleep to awakened, and when fully awake. The ability to transition from one state to another without disruption of physiologic homeostasis is a precursor to normal cognitive and motor development. When the state systems are well organized, infants usually have periods of restful sleep with easy transition from one state to another. Organized infants also normally show periods of quiet alert and demonstrate a relaxed, calm, awake state. The cortically disorganized infant may sleep with frequent squirms, irregular activity, irregular respirations, and abrupt changes from awake to sleep or sleep to awake. Such infants may be fussy, irritable with sudden arousal, and abnormally reactive to environmental stimuli and appear fragile. At times the brightness of the room may interfere with the infant’s ability to regulate external stimuli. Because of these distractions some infants may look away or avert their gaze when stimulated with face-to-face contact. The alert state is assessed by observing their interaction with caretakers during an alert state.

Disorganization in state systems can range from mild to severe. Mild sleep disorganization is characterized by generalized jerky movements, facial twitching or grimacing, or an irregular respiratory pattern. The transition from a sleep to awake state with mild drowsiness and diffuse movements with whimpers may be common. When awake, infants are alert and quiet with minimal motor activity or they are briefly fussy. Moderate disorganization is characterized by frantic movements while infants are awake with an unsteady respiratory and heart rate. Often they are irritable and fussy. Severe disorganization is characterized by hyperalert states with a look of panic or fear, which may be followed by motor flaccidity and inactivity. Once infants are overwhelmed by external stimuli they may not respond to any further stimuli.

Attention System

Close observation of the duration and quality of the alert state and the degree to which the infant is available to interact with his or her environment are important. Disorganized patterns of attention are often consistent with eye gaze aversion or closing, poor attention to task, or hyperactivity followed by inactivity during periods of stimulation. Other issues that should be addressed include whether the infant attends to social stimuli and inanimate objects or if the infant is able to transition to an alert state independently or needs assistance. In addition, does the infant actively inspect the environment, and is the attention to that environment controlled?

Self-Regulatory System

Self-regulation is demonstrated by how well the infant can maintain a deep or quiet sleep state or maintain a calm state when alert. It is important to observe the strategies the infant uses to accomplish the task of maintaining a calm state. Baseline measures of how long the infant is able to maintain this state should be made. Observations of the amount of effort needed to achieve this state and the amount of external support needed should be documented.

History

A comprehensive history should be completed, including gestational age, adjusted age, birth weight, and any abnormalities associated with the birth. Apgar scores, perinatal complications, hospitalization history, cardiopulmonary history, any radiologic or ultrasound procedures, and laboratory values should be reviewed for any abnormality.

State Systems

The sleep, transition to awake, and awake states should be assessed as previously described.

Posture and Tone

These factors include the infant’s posture and tone in various positions. Infants who are born at 28 to 32 weeks are more hypotonic in the upper and lower limbs. As infants mature they demonstrate increased tone—increased flexion in the lower extremities followed by the upper extremities. The developmental specialist assesses reflexes and positions expected at certain maturity levels, which hopefully correlate with the estimated gestational age of the infant. Clinicians look at active tone in prone suspension, slip through, trunk support, neck flexors and extensors, and lower extremity abilities. Posture and passive tone positions include the infant’s posture when supine, in a heel-to-ear maneuver, popliteal angle, scarf sign, and return to flexion of the forearm to determine the age of the infant. It is also important to observe midline orientation, head and neck control, overall postural control, and movement patterns to ascertain the effects of the tone on feeding.

Reflexes

Certain reflexes are seen early in the infant’s life, and others emerge later in maturity. By 28 to 32 weeks’ gestational age, the infant demonstrates the rooting, sucking (weak at 28 weeks), plantar grasp, flexor withdrawal, extensor thrust, and poor responses to the crossed extension and Moro reflexes. By 32 to 36 weeks’ gestational age, the infant demonstrates a more refined root (including head turning), suck (inconsistent irregular), palmar grasp, the Moro reflex in the lower extremities, Galant reflex, neonatal neck righting (at 34 weeks), proprioceptive placing of legs (35 weeks), neonatal positive support (35 weeks), and the emergence of the tonic neck (asymmetric tonic reflex [ATR]). All these reflexes are more refined and present by 36 to 40 weeks’ gestational age.

Adaptive Responses

An infant’s response to touch during bedside care and procedures and during feeding become more organized and mature the older the gestational age. From 32 to 34 weeks’ gestational age, infants may respond poorly to handling and be easily stressed. They may be difficult to console and are unable to self-regulate without external support. They may be inattentive or demonstrate brief responses to stimuli. Infants at this age may not focus or can only briefly follow a stimulus. Some stress signs may include hiccups, sneezes, passing gas or having bowel movements, nasal flaring, cries, splaying of arms and/or legs, arching, gaze aversion, and no apparent response to external stimuli. As infants mature, their responses become more controlled.

Physiologic Stability

In general, the earlier the gestational age the more unstable the infant’s ability to regulate physiologic stability. The clinician should observe the infant’s baseline cardiac and respiratory function (rate and depth of breathing), and color. When testing motor activity during feeding, it is important for the clinician to observe the infant’s physiologic response to the potential stress of this activity. This includes assessing possible changes in respiratory patterns resulting from the work of breathing. Increased signs of stress such as nasal flaring, use of respiratory accessory muscles, respiratory fatigue, an ability to modulate nonnutritive suck patterns, cry, and postural retractions should be documented. It may be important to monitor the patterns of oxygen saturation during feeding versus sleep. Evaluating the sounds of respiration is important. Normal breathing is smooth and effortless. Extraneous noises may indicate a problem of dynamic airway compliance. Observations of changes in skin color or cardiac rate and rhythm should be made because they may change as respiratory patterns change due to the demands of any external task involving motor activity.

Oral Reflexes

Assessment of the sensory and motor components of the facial and intraoral structures is essential before the infant attempts oral feedings. The clinician should observe the infant’s oral structures at rest and in response to light touch on the face, lips, and intraorally. Normally infants enjoy playful/light touching in their mouths. Their response to the placement of a finger or pacifier in the mouth should be observed. Was the response one of pleasure or did it markedly alter the infant’s baseline homeostatic state? Reflexes that are present in utero, at birth, and throughout one’s lifetime are the gag, cough, transverse tongue, and swallow. Oral reflexes that should be present after birth are the rooting (32 weeks up to 6 months), sucking (17 weeks up to 4 months), palmomental (see below, birth to 3 or 4 months), Santmyer (see below, 34 weeks to 1 to 2 years), and phasic bite (28 weeks to 9 to 12 months). These reflexes assist in the acquisition of food but disappear or are integrated by muscle function at the aforementioned intervals.¹¹

The rooting reflex is elicited by stroking the perioral area, which normally results in the infant turning toward the stimulus and opening the mouth. Notation of the presence, inconsistency, or absence of the rooting reflex should be made. The suck is assessed with a gloved finger placed in the infant’s mouth to feel the strength and rhythm of the suck as well as the function of the tongue. The gag reflex is elicited by placing a little finger in the posterior oral cavity. Observe if the reflex is present, diminished, or absent. The palmomental reflex is elicited by providing bilateral, quick pressure on the palms. The normal response in newborns is depression of the mandible and an accompanying sucking motion. The Santmyer reflex is tested by delivering a quick puff of air to the perioral area of an infant who is awake. Normally, this elicits a swallow. The phasic bite reflex is elicited by stimulating the molar region on the mandibular ridge. Normally this results in a rhythmic up-and-down movement of the mandible. The characteristics of the tongue are evaluated by noting the shape of the tongue, the frenulum, symmetric movements, and if the tongue moves up, down, and laterally. The shape of the hard and soft palates, the buccal musculature, and pharynx should be inspected before any feedings.

Nonnutritive Suck

The nonnutritive suck is the key to neurologic readiness for feeding and neurologic integrity. The nonnutritive suck is elicited by using either a little finger or a pacifier inside the infant’s mouth. The normal rate should be 2 sucks per second, and if possible, sucking should be evaluated for at least 1 minute to evaluate any signs of fatigue. It is important to look and feel the strength, rhythm, endurance, impact on breathing, speed, and general motor organization. Does the infant demonstrate a strong, sustained, and rhythmic suck, or is it weak, irregular, and interferes with normal respiration?

Nutritive Suck

Before assessing a nutritive suck the infant needs to be in a quiet, alert state and hungry. Ideally this evaluation should be done in a quiet setting without potential distractions. The clinician should see if the infant is rooting and shows an interest in feeding. Some institutions orally feed an infant with a nasogastric tube in place, and some remove the tube and reinsert it after feeding if necessary. The preterm infant should be swaddled in a blanket for proper containment and positioning during the feeding. The clinician assesses which feeding position is most beneficial. Positions vary from the cradle hold, upright facing away from the caretaker, facing the caretaker, or side-lying. The infant’s lower lip or corner of the mouth is touched with a nipple from a breast or bottle to elicit a rooting reflex. Once the infant provides the open-mouth gesture, the nipple is placed on top of the tongue. Normally, the infant leads the progression and length of feeding, including pauses from and resumption of sucking. It is important to document the strength, rhythm, endurance, speed, and motor organization of the suck. The clinician notes again if the feeding process affects the infant’s breathing patterns, the coordination of the dynamics of the suck and swallow bursts, and the overall pattern of sucking. Normal nutritive sucking occurs at a rate of 1 suck per second. The sucking “bursts” can be as many as 10 to 30 followed by a pause for breathing. The healthy term infant demonstrates continuous sucking and swallowing bursts and integrates breathing effortlessly within the bursts. A full feeding should last from 15 to 20 minutes. This time frame allows the feeding specialist time to evaluate the infant’s response to the feeding and stability of all the subsystems that support normal feeding.

Videofluoroscopic Swallowing Study

The videofluoroscopic swallowing study (VSS) for preterm and term infants is usually completed in the upright lateral position using special supportive devices for proper positioning. A Tumble Form seat (Patterson Medical/Sammons Preston, Bolingbrook, Ill.) can be placed on a chair and adjusted to upright and semiupright positions. For preterm and term infants, only liquid barium is used to ascertain the safety of oral feedings. At 5 to 7 months it is common to use a variety of pureed foods and fluids. Once the infant is 12 months old, more textures and viscosities are used in the assessment. The infant is tested with thin liquid barium with a bottle and nipple. A variety of nipples and bottles with variable flow rates may be used to determine whether the infant can tolerate liquids safely. The clinician may need to pace the infant throughout the procedure for safe swallowing, and at times the liquid barium may need to be thickened for the infant to tolerate oral feedings safely. Assessment of the oral phase includes observations of the organization of the suck-swallow-breathe sequence, the amount of bursts the infant is capable of performing, the position of the lips and tongue on the nipple, and head position. Infants may channel barium into the valleculae before initiation of the swallow; this is considered part of the normal swallow.12,13 If the pharyngeal phase is slow or demonstrates reduced motility, the child may be at risk for aspiration. Infants may not show overt signs of coughing during aspiration. Usually aspiration is seen in the anterior trachea. When the infant is positioned properly, the esophageal phase can be evaluated. Ideally there will be a strong primary peristaltic wave that clears all material through the lower esophageal sphincter into the stomach. A normal secondary wave may be seen (independent of a swallow) to clear any residual material through the lower esophageal sphincter. The esophageal phase should be completed in 6 to 10 seconds. The radiologist should document any dysmotility, obstruction, stricture, or tracheoesophageal fistula.

Videofluoroscopic Swallowing Study and Upper Gastrointestinal Series

A combination of the VSS and an upper gastrointestinal series may be completed during the same procedure (Video 11-1). This can provide the medical team with a more comprehensive evaluation of the entire deglutitive process. The procedure starts with the infant in the upright position using a bottle filled with barium using the appropriate nipple flow rate that the infant can tolerate for safe oral feedings. The flow rate is determined by the clinical evaluation. Once the clinician ascertains that the infant is not aspirating or is unable to feed without aspiration, the infant is placed in the supine position and fed with the same bottle and nipple. This position allows the clinician and the radiologist to assess the integrity of the esophageal phase without gravity and to determine whether the infant shows signs of gastroesophageal reflux. If the infant is unable to take orally the total amount needed for the assessment, the barium may be syringed into the nasogastric tube to fill the stomach with the appropriate amount of barium to evaluate the lower gastrointestinal tract to demonstrate possible gastroesophageal reflux. Premature infants commonly demonstrate reflux. The following points are important for the clinician to consider:

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